North Carolina Oral Surgeon's License Revoked After Patient's Death

Officials say a North Carolina dentist over-scheduled his practice to such an extent that he had little time to evaluate patients before or after oral surgeries.

A North Carolina oral surgeon has lost his dental license after state regulators say he routinely over-booked his surgery schedule, leaving little or no time to properly evaluate patients before procedures or ensure procedures were completed in accordance with patient safety standards. Such practices ultimately contributed to the death of a tooth extraction patient in 2010, the state dental board said.

John S. Won, DDS, MD, an oral surgeon working at a clinic in Cary, NC, had his dental license revoked by the North Carolina State Board of Dental Examiners in late July after the board found him guilty of misconduct and acting unethically in the treatment of an unidentified male patient who died after having teeth pulled. The patient saw Won in February 2010 and died within 48 hours after having the surgical procedure as a result of cardiac arrest secondary to hemorrhagic shock.

According to a record of the proceedings, the patient was scheduled for tooth extraction at 10 a.m. Before seeing the patient in question, Won had no fewer than nine surgeries scheduled on other patients. The board also found that, between the patient’s appointment at 10 a.m. and noon the same day, Won was booked for several patient consultations and six other oral surgeries.

Information from the clinic’s anesthesia and treatment records showed that Won had only five minutes at most before finishing the surgery prior to the patient’s appointment at 10 a.m. and the start of the patient’s tooth extraction procedure. Further, the board found that Won failed to adequately assess any of his patients before the start of any procedures, including the patient in question. The board said treatment records for multiple patients were identical—records were not completed or changed to reflect individual patients’ circumstances, including the record of the patient that died.

Won was also found to have scheduled his practice differently for patients, depending on if they had private insurance or Medicaid. Office staff were apparently instructed to book all five of the time slots per hour for every hour of the day the practice was open, but only on days that Won was seeing Medicaid patients. Also, almost none of the Medicaid patients were assessed, consulted, or examined prior to their procedures.

In addition, the dental board found that the clinic fraudulently billed Medicaid for surgeries, oral evaluations, CT scans, and other procedures that were not performed, as well as for medications that were never administered. The News & Observer reported that Won’s attorney has said Won has already reimbursed the government for approximately half of the overbillings.

The dental board stated that Won “was negligent in the practice of dentistry…(and) committed acts constituting malpractice in the practice of dentistry.” The board’s findings noted that Dr. Won’s “misconduct involved such serious, numerous violations of the Dental Practice Act and the rule of ethics governing professionals that revocation is the only discipline sufficient to protect the public.”